Quality of Life: A Post-Pandemic Philosophy of Medicine
by Robin Downie. (Exeter: Imprint Academic, 2021)
Which patient should be saved when not all can be saved? Cure, care, or prevention: which should have priority under what circumstances? The coronavirus pandemic has drawn politicians and the public into ethical debates long familiar to physicians and philosophers; and how well or badly the moral complexities of such debates are understood will be important for everyone's post-pandemic quality of life. No better guide to understanding these complexities then than Robin Downie, whose Quality of Life: A Post-Pandemic Philosophy of Medicine
addresses them in the best traditions of Scottish philosophy – with communicative clarity and with common sense.
In response to the moral complexities of medical ethics, Downie writes, we need first to understand 'what contemporary medicine is aiming at', where it has come from, and 'what future direction of medicine is desirable if medicine is to be fit for the new sort of post-pandemic society which is emerging'. The ethos of contemporary medicine, reflecting its roots in the Hippocratic tradition of medicine as an applied science, he notes, relies heavily on 'a belief in science as the sole evidence-base for diagnosis and treatment and social science as the basis for communication': but while this may have 'mainly good consequences for patients', it attributes an unrealistic degree of certainty to evidence-based medicine and tends to seek 'medical solutions to all the problems of life'.
Happily, another, albeit currently less dominant aspect of medicine, is found in the even older Asklepian tradition of 'inner healing', which emphasises 'quiet listening and waiting' and complements the technical aspects of medicine with an emphasis on healing relationships, both between doctor and patient, and 'in the way people relate to each other in communities and the environment'.
While medical practice is properly regulated by codes of ethics and medical ethics is now taught as part of the curriculum in medical schools, Downie notes, 'what is taught is medical ethics, or ethics from a medical point of view'; and the approach adopted all-too-often assumes that 'the complexity of our lives as moral beings can be distilled into four principles peculiar to medicine'. Advocacy of these principles, he suspects, 'may have made the ethical practice of doctors worse than it would otherwise have been'.
This may sound a trifle harsh, but as Downie points out, focusing only on principles ignores or oversimplifies no less critical philosophical questions concerning, for example, 'the adverbial side of morality – when, how and how much to communicate decisions', or 'how to become a person who makes sound judgements – the self-development side of morality'. While 'medical training and practice inevitably require a narrow focus', understanding the 'many and complex ways in which human beings and communities interact' requires a broader focus; and 'exposure to the arts and humanities' in practice contributes to 'the development of sound clinical judgement which, despite the prevalence of algorithms, remains an essential requirement of a good physician or surgeon'.
Seen in this broader focus, Downie argues, doctors may 'say that their basic aim is to improve quality of life': but 'quality of life' can no longer be regarded as 'something individualistic which can be supplied by doctors and is quantifiable on a scale one-to-10'. Rather than being 'narrowed down' to something 'health-related', quality of life needs to be seen as having 'many non-medical aspects such as equitable relationships among the members of a community, the provision of material and cultural goods and a green environment'.
One practical example of what this might involve is 'social prescribing' by GPs, 'defined as a range of approaches to linking people to non-medical sources of support', such as 'arts and cultural activities, green space, debt advice, physical activity and leisure, bibliotherapy, earning, volunteering, housing advice, benefits, employment and legal advice'. Social prescribing, Downie suggests, 'can be used as a possible remedy for many of the problems of life, problems which indeed have an impact on health, especially mental health'. At the same time, however, he warns, 'without equity in the distribution of wealth', no 'amount of social prescribing can solve the problems thrown up by a broken society'.
An even broader focus therefore is required, in which medicine works 'not top-down in the community but alongside the care sector and the various other community and environmental agencies concerned with our health'. Ultimately (and as COVID-19, he believes, has highlighted), 'health is a way in which people relate to each other and the environment'.
Downie's advocacy of this imaginative vision for post-pandemic medicine is complemented by his lucid and very readable analysis of philosophical concepts and of current controversies in medical ethics: the nature of scientific understanding, social justice, communitarianism and value all are helpfully examined as are the ethics of consent, incapacity, assisted suicide and genetics. All that Downie writes in Quality of Life
is informed, timely and challenging: a very rich and rewarding contribution to what we ought all to be thinking about as we look forward to a post-pandemic future.
Kenneth Boyd is Professor Emeritus of Medical Ethics at the College of Medicine and Veterinary Medicine, University of Edinburgh